Pregnancy at Risk Flashcards
(106 cards)
1
Q
Non-Stress Test
A
Evaluation of fetal well-being
Reactive: 2 accelerations of 15 bpm lasting 15 seconds or more over 20 minutes
Nonreactive: reactive criteria not met
2
Q
Biophysical Profile
A
Assessment of 5 variables to evaluate fetal status
- Score 1-10, 2 points for each variable
3
Q
5 Variables of the Biophysical Profile
A
- Breathing movement (U/S)
- Body movement (U/S)
- Tone (U/S)
- Amniotic fluid volume (U/S)
- Fetal reactivity (NST)
4
Q
Obesity in Pregnancy
A
BMI of 30 or greater (pre-pregnancy)
- Preventative is the best therapy!!!!
5
Q
Medical and Obstetric Complications in Obese Pregnant Women (Early Pregnancy)
A
- Spontaneous abortion
2. Congenital anomalies (NTDs)
6
Q
Medical and Obstetric Complications in Obese Pregnant Women (Late Pregnancy)
A
- Gestational HTN/preeclampsia
- GDM
- Preterm delivery
- Intrauterine fetal demise
7
Q
Medical and Obstetric Complications in Obese Pregnant Women (Post Partum)
A
- Endometritis
- Wound breakdown
- Thrombophebitis
8
Q
Medical and Obstetric Complications in Obese Pregnant Women (Fetus/Neonate Risks)
A
- Macrosomia (birth weight greater than 4 kg)
- Fetal obesity
- Childhood obesity
- Fetal demise
9
Q
What is an abortion?
A
Expulsion of embryo or fetus before it is viable (can be spontaneous or induced)
10
Q
Threatened Abortion
A
A threatened abortion refers to vaginal bleeding during the first 20 weeks of pregnancy, which can be an indication of a possible miscarriage. Many women who experience a threatened abortion will still be able to carry the pregnancy to term.
11
Q
Inevitable Abortion
A
- Vaginal bleeding (greater than that of threatened abortion)
- ROM
- Cervical dilation
- Strong abdominal cramping
- Possible passage of products of conception
12
Q
Incomplete Abortion
A
- Passage of some of the products of conception
- Cervical dilation
- Intense abdominal cramping
- Heavy bleeding
13
Q
Complete Abortion
A
- Passage of all products of conception
- History of vaginal bleeding and abdominal pain
- No medical or surgical intervention necessary
14
Q
Missed Abortion
A
- Non-viable embryo retained in utero for at least 6 weeks
- Absent uterine contractions
- Irregular spotting
- Possible progression to inevitable abortion
15
Q
Habitual Abortion
A
- History of three or more consecutive spontaneous abortions
16
Q
Reason for spontaneous abortion during 1st trimester
A
Congenital
17
Q
Reason for spontaneous abortion during 2nd trimester
A
Maternal
- Incompetent cervix
- Uterine anomaly
- DM
- Acute infections like CMV, rubella, herpes, toxoplasmosis
- Drug use
18
Q
Timeline for Medical Abortion
A
Up to 9 weeks gestation
19
Q
First Line Method for Medical Abortion
A
- 90-98% successful
- Methotrexate then misoprostol 3-7 days later
- Methotrexate is toxic to trophoblastic tissue (growing embryo)
- Misoprostol (prostaglandin) causes uterine contractions which ripens the cervix (causes N/V)
20
Q
Second Line Method for Medical Abortion
A
- 95% effective up till day 49 of LMP
- Mifepristone (progesterone antagonist) RU-486 (blocks action of progesterone)
- Misoprostol 48 hours later
21
Q
Types of Surgical Abortion
A
- Dilation and suction/aspiration
- Dilation and evacuation
- Dilation and extraction
22
Q
Timeline for dilation and suction/aspiration
A
Up to 12 weeks
23
Q
Timeline for dilation and evacuation
A
12-20 weeks
24
Q
Timeline for dilation and extraction
A
Third trimester abortions
25
When will menstruation resume after an abortion?
Within 6 weeks
26
Abnormal Findings After Abortions
1. Heavy bleeding
2. Intense cramping
3. Fever
4. Foul discharge or odor
27
What is an ectopic pregnancy?
The implantation of a fertilized ovum in a site other than the endometrial lining of uterus.
- Ampulla of fallopian tube most common site
- Normal symptoms of pregnancy may be present early
28
Factors contributing to ectopic pregnancy
1. Pelvic inflammatory disease
2. Endometriosis
3. Presence of IUD
4. Previous tubal surgery
5. Previous ectopic pregnancy
6. Congenital tubal anomaly
7. DES exposure (chemical exposure)
29
S/Sx of Ectopic Pregnancy
1. Number 1 symptom is amenorrhea
| 2. Vaginal bleeding when embryo dies (may begin with dark brown spotting)
30
Symptoms of Tubal Rupture (ectopic pregnancy)
1. Intraabdominal bleeding
2. Sharp, one-sided pain (peritoneum irritated from bleeding)
3. Syncope
4. Referred shoulder pain
5. Adnexal tenderness (mass may or may not be palpable)
6. Abdomen becomes rigid, tender
7. Extensive bleeding leading to hemorrhage leading to shock
31
Ectopic Pregnancy Diagosis
1. hCG levels
| 2. USG-TV (transvaginal)
32
Surgical Treatment for Ectopic Pregnancy
1. Laparoscopy with salpingostomy (tube left open)
| 2. Laparoscopy with salpingectomy (tube removed) if the tube is ruptured
33
First thing to do when a fallopian tube ruptures?
Immediate IV line to compensate for impending shock
34
When is a pharmacological treatment for ectopic pregnancy indicated?
1. When the fallopian tube has not ruptured
2. 4 cm size or less
3. No fetal cardiac motion
4. Stable condition - no evidence of acute abdominal bleeding, blood disorder, kidney or liver disease
35
Medical Treatment for Ectopic Pregnancy
Methotrexate IM
- 2nd injection may be necessary
- Serum hCG titer monitored (may rise for 1-4 days but then decline)
- Transient abdominal pain (will not be a sharp or referred pain) (4-12 hours); must differentiate between pain of ruptured fallopian tube
36
Placenta Previa?
- Placenta is positioned over the cervix and the baby is above it
- Can cause bleeding during 2-3 trimesters
- Graded according to its location in relation to cervical os
37
Total placenta previa
The internal cervical os is completely covered by the placenta
38
Partial placenta previa
The internal os is partially covered by the placenta
39
Marginal placenta previa
The placenta is at the margin or edge of the internal os
40
Low-lying placenta previa
The placenta is implanted in the lower uterine segment and is near the internal os but does not reach it
41
Management of Placenta Previa depends on what?
1. Gestational age
2. Amount of bleeding
3. Tolerance of mom and baby
42
Management of Placenta Previa
1. Can wait to see how it progresses
2. Can be admitted to antepartum care
- Monitor for contractions
- Avoid vaginal exams
- Assess bleeding levels
43
Hydramnios
Too much amniotic fluid (more than 2000 mL) surrounding fetus between 32-36 weeks
- Seen in gestational diabetes
- Low apgar scores and poor tolerance to labor
- Preterm births, cord prolapse, and fetal malpresentation
44
Treatment for Hydramnios
1. Monitoring closely
- Fluid can be removed but its risky to the fetus
- A non-invasive treatment may involve administering indomethacin to decrease amniotic fluid volume by decreasing fetal urinary output, but this may cause the premature closure of the fetal ductus arteriosus
45
S/Sx of hydramnios
1. Discrepancy between fundal height and gestational age
2. Complaints of abdominal discomfort (such as being severely tight or stretched)
3. Reports of uterine contractions
4. SOB
5. Often fetal HR is difficult to obtain because of the excess fluid present
46
Oligohydramnios
Decreased amount of amniotic fluid (less than 500 mL) at 32-36 weeks
- Results from fetus being unable to produce urine or urine being blocked from the amniotic sac
- Increased risk for fetal hypoxia and cord compression
- Once born worry about kidney function and swallowing issues
47
Treatment for oligohydramnios
1. Frequent monitoring to ensure fetal well being
| 2. If fetal well being is compromised, then delivery and amnioinfusion are ordered
48
Hyperemesis Gravidarum
Excessive vomiting during pregnancy
49
S/Sx of hyperemesis gravidarum
1. Weight loss
2. Dehydration
3. Ketonuria
4. Fluid-electrolyte imbalance
5. Hypovolemia
6. Hypotension
7. Tachycardia
8. Increased Hct and BUN
9. Decreased urine output
10. Metabolic acidosis
50
Causes of hyperemesis gravidarum
1. Hormones (increased hCG, estrogen, progesterone)
2. Decreased GI motility
3. Psychological factors
4. Abnormalities of corpus luteum
5. H. pylori
51
When does hyperemesis gravidarum usually occur?
The peak incidence is at 8-12 weeks, and symptoms usually resolve by week 20
52
Treatment/Management of hyperemesis gravidarum
1. IVF possible TPN for most severe
2. Antiemetics
3. ID and avoid triggers (smells, sights...)
4. Cool room temp
5. Prenatal vitamins at night
6. Do not use a straw to drink, sip between meals - do not drink with a meal
7. Small frequent meals every 2-3 hours - never too hungry never too full
8. Crackers before getting out of bed in morning
9. Avoid greasy, spicy foods
10. Weak tea,, ginger tea, very cold carbonated beverages, fruit juices
11. Sit upright after meals
53
Hypertensive Disorders During Pregnancy
1. Preeclampsia-Eclampsia
2. Chronic hypertension
3. Chronic hypertension with superimposed preeclampsia or eclampsia
4. Gestational (or transient) hypertension
54
Chronic hypertension
Hypertension that exists prior to pregnancy or that develops before 20 weeks gestation
55
Gestational hypertension
Blood pressure elevation (140/90) identified after 20 weeks gestation without proteinuria. Blood pressure returns to normal by 12 weeks postpartum
56
Preeclampsia
Most common hypertensive disorder of pregnancy, which develops with proteinuria after 20 weeks gestation. It is a multi-system disease process, which is classified as mild or severe, depending on the severity of the organ dysfunction.
57
Eclampsia
Onset of seizure activity in a woman with preeclampsia
58
Chronic hypertension with superimposed preeclampsia
Occurs in approximately 20% of pregnant women with increased maternal and fetal morbidity rates
59
Preeclampsia Pathology
1. Gradual loss of resistance to angiotensin II
2. Blood pressure rises (HTN)
3. Vasoconstriction and platelet aggregation occur
4. Loss of normal vasodilation of uterine arterioles and maternal vasospasm
- Decreased placental perfusion
5. Decreased renal perfusion (BUN, Creatinine, Uric Acid increase)
6. Urine output decreased
60
Preeclampsia Decreased Renal Perfusion
1. Increased BUN, creatinine, uric acid
2. Kidneys filter protein into urine (proteinuria)
3. Loss of protein from vessels (hypoalbuminemia)
61
Preeclampsia Urine Output Decreased
1. Increased extracellular volume (edema)
| 2. Increased sensitivity to angiotensin II
62
When is preeclampsia most often seen?
- Last 10 weeks of pregnancy
- During labor
- First 48 hours after birth
63
Women at Risk for Preeclampsia
1. Teenagers
2. Greater than 35 years old
3. Hx of preeclampsia
4. Large placental mass associated with multiple gestation
5. Rh incompatibility
6. DM
7. Any vascular disease
8. Obesity
9. Familial tendencies
10. Malnutrition
11. Race
12. First pregnancies
64
Cardinal Signs of Severe Preeclampsia
1. BP greater than 160/110 X2 (6 hours apart)
2. 24 hour urine with proteinuria greater than 5 gm
3. Dipstick urine protein 3+, 4+
4. Oliguria: urine output less than 500 mL/24 hours OR less than 30 mL/hr
65
Other S/Sx of Severe Preeclampsia
1. Frontal headache
2. Blurred vision
3. Scotoma (spots/eyes)
4. Cyanosis
5. Pulmonary edema
6. Epigastric pain or RUQ pain (secondary to increased vascular engorgement of liver)
7. Impaired liver function (elevated liver enzymes)
8. Irritability
9. Seizure
10. Hyperreflexia (DTR 4+)
11. Clonus
12. Retinal edema
13. Edema (weight gain 3lb/24 hours OR 4lb in 3 days)
14. Thrombocytopenia (less than 100,000)
15. HELLP syndrome
66
HELLP Syndrome
H - hemolysis (low RBC and platelets)
E - elevated
L - liver enzymes (LDH, AST, ALT)
L - low
P - platelets
** Early diagnosis is critical to prevent liver distention, rupture, and hemorrhage and the onset of DIC
** If the condition present prenatally, morbidity and mortality can affect both mother and baby
67
Placental/Fetal risks during Preeclampsia
1. Hypoxia of fetus
2. Malnutrition of fetus (SGA, IUGR)
3. Premature aging of the placenta (can see late decels)
4. Abruption of placenta
5. Preterm delivery
68
Maternal Risks of Preeclampsia
1. Stroke
2. Heart failure
3. Acute renal failure
4. Acute liver failure
5. Pulmonary edema
6. Death
69
Lab Tests for Preeclampsia
1. 24 hour urine for protein and creatinine clearance
2. Increased serum creatinine, BUN
3. Increased liver enzymes
4. Electrolytes
5. CBC with platelets (less than 100,00)
6. Clotting studies if thrombocytopenia
70
Management of Preeclampsia
* * Clinical therapy depends on severity of disease
1. Fetal status monitored by kick counts, NSTs, BPPs, USGs
2. Increase protein intake to 80-100 mg/day
3. Sodium restriction NOT indicated - should be moderate (less than 6 gm/day)
4. Quiet environment
5. Seizure precautions
6. Bedrest left lateral position
7. Daily weight, BP, protein at home
8. Check DTRs
9. Mom needs to report s/sx of increasing severity
71
Medications Used with Preeclampsia and Eclampsia
1. Magnesium sulfate
2. Hydralazine HCl
3. Labetalol
4. Nifedipine
5. Sodium nitroprusside
6. Furosemide
72
Magnesium sulfate
CNS depressant
- Raises seizure threshold (SE is lowered BP)
- Therapeutic level is 4.8-9.6
73
Side Effects of magnesium sulfate
1. Hot flush
2. Sweating
3. Nasal congestion
4. Hypotension
5. N/V
6. Lethargy
7. Drowsiness
8. Weakness
74
Symptoms of magnesium sulfate toxicity
1. Urine output less than 30 mL/hr
2. RR less than 12/min
3. DTRs 0 or no response
4. Confusion
5. Unable to arouse
6. Circulatory collapse
75
Antidote for Magnesium Sulfate
Calcium gluconate (1 gm dose IV over 3 minutes)
76
Betamethasone
Administered to the woman whose fetus has an immature lung profile; stimulates enzyme necessary for production of surfactant to induce pulmonary maturation and decrease risk for RDS in preterm infants.
* * If the baby has to be delivered early in preeclamptic/eclamptic mother
- 12 mg IM every day for 2 days (gluteal deep IM)
77
Contraindications for Betamethasone
1. Inability to delay birth
2. Adequate L/S ratio
3. Gestational age greater than 34 completed weeks
78
Antihypertensives used for Preeclampsia
1. Hydralazine - most common in IV boluses
2. Methyldopa - long term control of mild to moderate HTN
3. Labetalol - also used long term control of HTN; 2nd line IV drug; avoid in asthma and CHF
79
Medications Used in Management of Eclampsia
1. Magnesium sulfate bolus
2. Diazepam
3. Dilantin for seizure prevention
4. Furosemide
5. Digitalis for circulatory failure
80
Cure for Preeclampsia/Eclampsia
The birth of fetus and delivery of placenta (the best option is delivering vaginally because mom isn't good at clotting)
81
Gestational Diabetes
Any degree of glucose intolerance that has its onset or is 1st diagnosed during pregnancy
82
Class A1 Gestational DM
Managed by diet
83
Class A2 Gestational DM
Insulin dependent
84
Classes B-R
Diabetics before pregnancy, managed with insulin
85
Testing for GDM
All 24-28 weeks
- 1 hour 50 gm GTT (normal less than 140)
- 3 hour 100 gm GTT (2 or more abnormal values is a diagnosis)
1. FBS should be less than 95
2. 1 hour should be less than 180
3. 2 hour should be less than 155
4. 3 hour should be less than 140
86
Risk Factors for Earlier Screening (DM)
1. Older than 40
2. 1st relative with DM
3. Prior macrosomic, malformed, or stillborn infant
4. Obesity
5. HTN
6. Glucosuria
87
Insulin Requirements During Pregnancy (1st Trimester)
Decreased need for insulin perhaps due to N/V and fetal needs are low
88
Insulin Requirements During Pregnancy (2nd and 3rd Trimesters)
1. Insulin needs increase due to hPL production and increase glucose use
2. Insulinase secreted by placenta accelerates breakdown of insulin
3. Estrogen, Progesterone, Cortisol act as insulin antagonists
89
Euglycemia for Pregnancy
60 - 120 mg/dL
90
Hgb A1C
Average glucose over last 100-120 days
- Less than 7.5 (good control)
- More than 9.0 (poor control)
91
Fetal Testing in DM
1. USG - 18 weeks to establish gestational age and detect anomalies, repeat at 28 weeks for fetal growth
2. Fetal kick counts QD at 28 weeks
3. NST weekly at 28-32 weeks, may increase to twice weekly; if non-reactive, BPP (5 or 6 means you have to deliver soon)
92
Medications for DM
1. Insulin usually a mixture of NPH and Regular given - individualized
2. Oral hypoglycemics are used occasionally
3. Glyburide 1st choice for oral hypoglycemic, Metformin also used
93
Causes of Hypoglycemia
1. Too much insulin
2. Increased energy expenditure
3. Vomiting/diarrhea
94
S/Sx of hypoglycemia
1. Hunger
2. Sweating
3. Weakness
4. Cold, clammy skin
95
Treatment of hypoglycemia
1. Complex CHO, protein-prevents rebound effect
| 2. Hard candy if exercising
96
Causes of Hyperglycemia
1. Too little insulin
2. Infection
3. Decreased exercise
97
S/Sx of Hyperglycemia
1. Polydipsia
2. Polyuria
3. Polyphagia
4. Vomiting
5. Flushed, dry skin
98
Treatment of Hyperglycemia
Administer insulin
99
Maternal Risks Associated with DM
1. Hydramnios
2. Preeclampsia/eclampsia
3. Ketoacidosis - develops slowly can lead to coma and death of mom and fetus
4. Retinopathy - retinal hemorrhage possible; refer to ophthalmologist
5. Infection - monilial vaginitis and UTI due to increased glycosuria creating favorable environment for bacterial growth
100
Fetal Risks Associated with Diabetes
1. Congenital anomalies
2. LGA, excessive growth = macrosomia
3. Hypoglycemia
4. IUGR
5. RDS
6. Polycythemia
7. Hyperbilirubinemia
8. Fetal death due to placental degradation
101
TORCH Infections
```
T - Toxoplasmosis (cat litter)
O - other (syphilis, gonorrhea, chlamydia, group B strep)
R - Rubella
C - Cytomegalovirus
H - Herpes simplex virus
```
102
Group B Streptococcal Infection
Bacterial Infection
1. Colonized in lower GI and urogenital tracts
2. All OBs cultured, vaginally and rectally at 35-37 weeks
103
Neonatal Effects of GBS
1. Pneumonia
2. Overwhelming septicemia
3. Meningitis
4. Neurological complications
5. Death
104
Risk Factors for Neonatal GBS Sepsis
1. Preterm labor
2. Maternal fever during labor
3. Prolonged ROM (greater than 18 hours)
4. Previous infected neonate
5. Prenatal GBS bacteriuria
105
GBS Treatment
1. PCN - should be completed 4 hours prior to delivery
2. Prenatal bacteriruria treated in labor (GBS screen not necessary)
3. Women with prior neonate GBS+ receives prophylaxis - screening not necessary
4. Unknown status - antibiotics given if less than 37 weeks, ROM more than 12-16 hours, Temp higher than 100.4F
5. Treatment of neonate varies per facility/physician protocol
106
Hydatidiform Mole
Molar Pregnancy
1. Abnormal development of the placenta; appears as a fluid-filled grapelike cluster
2. Proliferation of trophoblastic tissue (outer layer of embryonic cells) that produce hCG
3. Major risk: Choriocarcinoma (cancer)
- High risk for hyperemesis gravidarium
- Not true pregnancy but tests positive due to production of hCG
- Can not get pregnant for 1st year after having it to make sure they don't have cancer.
